S 1771 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C11Y OF CUPERTINO BUILDING-ELECT RICA[. rE1 rr No.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANTCL
1771
BUILDING pROJECT IDEN'I IFICATION
BUILDING ADDRESS: SANITARY No APPLICATION SUI3MI ITAL DSII:
8'1(02 PAAV- Vim & C`kfz e cupc—(LTTNv
OWN13N'S NAME: 1'1I11N1i:
CON'I'It ACTORS NAMI3; LIC NO,
'
((LOIN SON O-SS-03 —Z EW—l' LLIO 'ss �S N/C cDry nun.a
�\RCHI'IFCT/ENGINEER: LIC No: ADDRESS: SAII0 f 9Sa ❑
!lo �NtiUsN
COMPACT: PHONE: BUILDING PIiRM1T INFO
❑ ConsuRanl Fees Paid by Applicant(Initial) HLD ELECT PLUMB MECO
❑ ❑ ❑
LICIiNSI?D CONTRACTOR'S DECLARA'DON QTV. P1.1'CTRIC PERMIT ' PEE
C m 7 I hefeby aatrnt mull mit liern,ttd.oder'an""nn.of Chapter ¢mmnaming TOR DESCRIPTION
O w1 Ill Scermn]IHXfofDivkdon3ofllle Businnrsabd Prnfcxsinns Clal itm censer,. RFSIDFNTIAI'
alp PERMI r ISSUANCE [I
1-IyF all famC�del ❑SFUWL CKI'ICHEY REh10Dlih
dVU Licc Oe Cl ss Co.k APPLIANCES—RUSIIIENTIAL ❑ADDITION ❑PLUMBING RE PIPE
FZW Umc Conwernr
wQa CDITI=S DECLA A I IN ❑MUI.TI-UNIT CSTRUCfURAL
F y Z I understand my plans shall M hied as public rcnnds PANIA S MODIFICATION
CZ_ UPT021XIAMPS []INTERIOR ❑CHIMNEY REPAIR
W ].!,a...it Profeaslonul 20I-10O)AMPS IMPROVEMENTE]SWIMMING POOLS
d �J OWNER-BUILDER DECLARATIONRA'II I RF,MODELAUTPAIR CDEMOLI'NON
C� J PS
C Q I fcrcby allinn that ani cxcn,pt from Nc Cnntrucmr's Liacnsc i.uw for the OVER IINNIAM
CU lodoos ng mason.(SfClinl,9031.5.[rosiness and VFOIC .Ons Code:Any City err umnly SIGNS EI.I:C I'RICAI. ❑(YI'lllik
W 3 WyQ which n' peb
yoncs a rmit )con wet.alley.Impmvc,dc...dish,Or npmr any Hmnurc
I�1=•OJ prior m its mrrne,.Norcyuiws life applicant for such Perna to Bill.egnW wacmcnt SPECIAL CIRCUI'TIMISC.
E I`Zy,Y that he is licensed pursuant it,the provisions of the Contractor's license Law(Chapter 9 COMMFRCIAI'
W�CO (Commencing with Section 7000)of Desilt.n 3 oldie Nasi,ic,..d Pmfesaioas Cale)or TEMP.MINTER OR POLE INST.
a ax c C ,bat he is exempt therefrom and the basis for the alleged e.ernpnoa.A.,vinta sort of ❑NEW BLDG/AUDITION ❑DEMOLITION
W Z
Section 70315 m. n by any applicant for a persubjecthe apPlicr, m
na civil pcuthy of POWER DEVICES CI'ENANT ❑FOOD SERVICE
vi
nal.tore than Eve hundred dollars 1551101 IMPROVEMENT
I✓yQ Cl.us awnw of iM1C PnipcnR ur my cmpinyccs with wngcx vx lhdrsulccnmpunvminn, SWIMMING ' Uh I!LHLTkIC
WFW w'lll 0 kn10 t t I I IJ if If IS .)1W411 CO'1'l1ER
3� a I Profe,,i is C d II C tractors L I I t ppll t .a Cancrot OU'li T SWI'ICIIS IIX'IUR13S �i
no,eny b bld 1 n
h d h does h kl If Ih bh NEW .l LELLC'R SU FT. • A
bis m eoyee. per v Jed that.such i p mems art n r intended or nrtenal for SQ.FT FLUOR AREA .5/SQ.1T.
sale.If.hmplowev,r.the building or improvement is anld within one ycar.f completion.the A��I(�
bey-builds,will hmc the burden of poring that he did not build or imp'nve for par- JUL 14 MST
rysw of salsJ. TOTAL:
0 I.s owner Of the property,ran eselusivdy comraeting with licensed Co,nonnrs Or
ntstmct the project(Seo.0(WJ.Business and Professions C,de:)The Conlan nr's Li
se low des notapplyloan owner of property who Milds or imposes thereon.mW QTY. PLUMBING PERMIT FEE GYTYUFW tHIINO
who nnractsfmsnchoill
lasw-'If aw
Concmr(s)lkrxw
cnwl pulnt ,,We Coommmnk
License Law. PERMI I'ISSUANCE
Ian,exempt under Scc .B&P C I.,'his Person
ALTER—DRAIN&VENT—WATER(RAI VALUATION
Owner ])are
WORKER'S COMPENSATION DECLARATION RACK R(lW PROTECT.DEVICE
1 hereby aRnb under pc„alty of perjury One of the following declarations:
1 have and will maintain a Certificate Of Consent n set r-insum for Workers Compen- DRAINS—FLOOR.ROOF.AREA.COND, STORIES 'TYPE CONSTRUCTION
ation...provided for by tion inn 3700 of the Lube,Code.Ea the performvnce it he
work for which this Penna is is>ucd. FIXTURES—PPR I RAI'
C I LiCa and dionamado Worker's Coanpien,nivni InOuraince,as required by Section
3]INI f0 1'b Code
W 1 11 1 era Irl kyylot misIh'�ilh�'t�h�is�l rmil is kd. CAS CA 1YS'I'hM-I INC,40UThli'I;S OCC GROUT' APN
IF�YrWrk per I Cti�Policy Noradcl'ohac/ludwr 'r•a3 11 GAS HA SYSI IM-OVER 4IRA)
CR 1FICAB OF EKEMPTION FROM WORKERS' GREASP/INIIUSTRI.WASTE INTERCEPTORCOhIPENSATION INSURANCE BUILDING DIVISION FTES
(This section need nal be canpleted if the plural Infinite hundred Collins($100) GREASE -
1'LANCHECK FEE
las.)
Toy any,hatper iniac any inanet so ahche-cone subjectch to the W is issued.alio -all SEWT:R—SANITARY—STORK EA.21X11'['.
not anpinY any person In wry n,ann.rsmcm bosoms subject the Woakerd Cnmpm HN[?RGY FEE
Z sudors Law s of Cal i l'nn.tu.Dam WATER IIEADin WNEN'VELECI'N GRADING FEE
z2 APPlkmn
y NOI'ICI;TO APPLICANT'.If alter making this Csnillcme of l3xcmption,you shouhi WATER SYS'1'Eh1/1'k1iATINC SOILS I'1i13
? hconre.Object to the Worker's Compensation pmvisioos ol'the Labor Code,you an,.
W .a limhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
I-All)
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDEN'I'IAl.['LMB. SQ.W. Dme Recap,e
U O Ihereby affirm that there n a conswction lending agency for me performunce of
Cl. — 'he walk for which this Penta,is i...N(Set.30'D,Civ.CJ
TOTAL:
C U LenJcrr NamC
Lender's Addie T(1'FA L:
W I Cenily tfal l fele rad this.pplicm.nn an t slate that the ubnvc it fmmxtiat is
BUILDING FEE
(A) c Cc..I."a.,,cantpl,1.11,.11 City and.nanny..Nannie,and."all laws rckem,to QTY. MECHANICAL PERMIT FEE
all
Z nuildingcnnvtmction,and hereby national mpOsenuake—f Itasca,Or cnmr.ptm the SHISMIC FEE
abn'omemioncd pngcny lirt inspection purry,us. PERMIT ISSUANCE E IA:c t RIC FEE
(Wel agree msave,indemnify and keep hanblas the City of Cupcaino against
Eialanies.judgarms.costs and expanses which may in any way racial against'"City ALTER OR ADD'TO MECH, PLUMBING FEE
in onsequence of the garbling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000 CFM) M17CIIANICAL FEE
SOURCE REOULATIONS.
AIR HANDLING ON['1'(OVER 10010 CPM[ CONSTRUCTION TAX
Signature of Applinmt/Conwclor 1)t, EXHAUST HOOD(WIDUC) HOUSING MITIGATION ITEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantoafumre building Occupant sato Or handle hazardous tmncnal HEATING U81'1'('10 IfgL000 BTU)
as dClinsd by the Cupeninn A
1u1'!
HEATING UNI[(OVER[00,000 BTU)
Code.Section 25532
C Yes s.
VENTILATION FAN(SINGLE RESID) EA[])
—Date Receipt M
Will 0e appticmn Or future building tncupum use cyuipmont or devices which BOILER—COMP(3IIP OR InLAXI R'FU)
it far rmJnm air mntun,ii oras nn define)by rife tray Arcu A r QnuEty Managenmm 'FOTM.:
ieu'in BQILBN—Cl IMI'[OVER IIXI,OIXI 13'1'lJl
❑Yes 7NO
I hien lthe houNnusarsenal,teaitemems under Chapter 695of the Cali- AIR CONDI'I'IONER �_11SUAN=G DATE
&Safety Cat .Scc' ns 255(A.li!11 and 255311 understand that if the NEW BESIDES HAI,MECH. SQ.VU
iMiagd tat cutmntly a Car .I t tisellyrw,nOiN_mnmify tnc,ccupam
,d n, wiremems whit Vt ears fiear Cary
c wnercrouthoriOcuag a IIWc HIM,: ISSOEDBY,
OFFICE